Incarcerated Small-Bowel Pericardial Diaphragmatic Hernia After Pericardio-Peritoneal Window Creation: Report of a Rare Case

Abstract

Patient: Female, 84-year-old

Final Diagnosis: Diaphragmatic hernia • small bowel obstruction

Symptoms: Abdominal pain

Medication: —

Clinical Procedure: Laparoscopic surgery

Specialty: Surgery

Objective:

Rare disease

Background:

Pericardio-peritoneal windows are surgically created to treat symptomatic pericardial effusion, usually of oncological origin, to alleviate cardiac tamponade-like symptoms. Common complications include infection, failure to drain the fluid correctly, and arrythmias. There are few published cases of intra-abdominal complications due to these interventions. This report discusses pericardial diaphragmatic incarcerated hernia, which is one such complication.

Case Report:

We report the case of an 84-year-old woman with advanced non-small cell lung carcinoma, who recently underwent surgery to create a pericardio-peritoneal window to treat a chronic malignant pericardial effusion. The patient presented in our Emergency Department because of abdominal pain with absence of flatus and stool for more than 4 days. Computed tomography scanning confirmed a proximal small-bowel obstruction due to incarcerated small bowel into the pericardial window. Reduction of the hernia was performed laparoscopically. After a bowel viability assessment by indocyanine green angiography, the pericardial window was covered by a noncovered macroporous mesh to avoid recurrence and to allow continuous pericardial fluid drainage.

Conclusions:

In case of abdominal pain after the creation of a pericardio-peritoneal window, we suggest the prompt use of computed tomography after initial examination. Indeed, although rare, a pericardial diaphragmatic hernia is possible and requires surgical exploration if there is a risk of bowel strangulation. The operation can be done laparoscopically, and the hernia repair should involve the placement of a nonabsorbable and noncovered macroporous mesh. This should prevent hernia recurrence, while also allowing adequate drainage of the pericar-dial effusion.